Signed (Treating Dentist) Date Specialty Code Number ©2006 ...

[Pages:1]ADA Dental Claim Form Sample

Unless the following sections of a dental bill are completed correctly, the bill will be returned and payment may be delayed.

Field

Section

Information Required

1 Header Information

Type of Transaction

12 Policyholder/Subscriber Information Name and Address

15 Policyholder/Subscriber Information ID (SSN / ID #)

18 Patient Information

Relationship to Policyholder/ Subscriber in box 12

20 Patient Information

Patient Name and Address

24 Record of Services Provided

Procedure Date

27 Record of Services Provided

Tooth Number(s) or Letter(s)

29 Record of Services Provided

Procedure Code

30 Record of Services Provided

Description

31 Record of Services Provided

Procedure Code Fee Amount

32 Record of Services Provided

Total Charges/Billed Amount

48 Billing Dentist or Dental Entity

Name and Address

50 Billing Dentist or Dental Entity

License Number

51 Billing Dentist or Dental Entity

Tax ID/SSN/FEIN Number of Payee as Registered with the IRS

52 Billing Dentist or Dental Entity

Phone Number

53 Treating Dentist and Treatment Location Information

Signature and Date

55 Treating Dentist and Treatment Location Information

License Number

56 Treating Dentist and Treatment Location Information

Address where services were rendered if different than box 48

57 Treating Dentist and Treatment Location Information

Phone Number if different than box 52

The CalVCB Claim Number must be written on the ADA Dental Claim Form.

For providers already in CalVCB's system: Number 48 and Number 51 on your bill must match exactly to what is in the system. If you have a new Tax ID, please notify CalVCB immediately.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download